II Whole-of-government approaches to health promotion
III Provincial and territorial initiatives
IV The need to step it up
--submitted by John G. Abbott, CEO, Health Council of Canada
With health care spending in Canada reaching an estimated $192 billion in 2010, there are serious and pervasive concerns about the sustainability of the health care system. The increasing prevalence of chronic conditions and growing health disparities are creating a sense of urgency about health promotion and disease prevention in Canada. But how do we achieve a healthier Canada?
Many Canadians think that lifestyle choices – maintaining a healthy diet, exercising, or not smoking – are the keys to good health. While these factors are important, research shows that the socio-economic, cultural and environmental conditions of our lives have an equally strong or even greater impact on our health. How governments can address these factors, called the determinants of health, is the subject of our report Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada.
Governments are beginning to realize that income, education, and other determinants of health have a significant effect on the population’s health and the overall costs to our health care system. As one example, an estimated 20% of total health care spending can be attributed to income disparities. We know that Canadians with the lowest incomes are more likely to suffer from chronic conditions like diabetes, arthritis and heart disease, as well as to live with a disability, suffer from mental illness, and die earlier. Low-income Canadians are twice as likely to use and re-use health care services compared to those with the highest incomes.
Historically, Canadians and their governments have seen the health of Canadians as solely the responsibility of government and its ministries of health (including health promotion and healthy living). Much of the government activity in health promotion has been focused on behaviour modification of lifestyle factors such as smoking or poor diet. There has been little attention paid to the broader factors (environmental, social, economic, and cultural) that shape these behaviours in the first place – or to a deeper analysis of these issues, which can be strongly affected by government policies. The majority of factors affecting health are complex and intertwined, requiring the problem-solving skills of multiple government departments across all levels of government, together with the community and private sectors. This is commonly referred to as a whole-of-government approach.
II Whole-of-government approaches to health promotion
The whole-of-government approach is built on changing the work of government from a focus on interventions by individual ministries or departments, to an integrated approach involving multiple government departments and non-governmental organizations working towards a common policy or program goal. To put it another way, if improving the overall health of the population is a policy goal, then this becomes not just the responsibility of health ministries, but the responsibility of all government departments that can influence the population’s health. This can mean significant organizational and cultural – if not structural – changes to a government’s approach to health issues, which can be challenging to implement.
In the Health Council’s report, Stepping It Up, we interviewed more than 30 senior-level officials from across the country, many of whom are trying to shift thinking towards a broader view of health and a whole-of-government approach. Many officials told us there is growing recognition of the need to tackle the determinants of health, and that the issue is being discussed with a new urgency.
III Provincial and territorial initiatives
We found that all jurisdictions have been working to strengthen health care and implement initiatives that support health promotion and disease prevention. Most notable in terms of whole-of government and intersectoral approaches are poverty-reduction strategies begun in recent years in the Yukon, Manitoba, Ontario, Quebec, Newfoundland and Labrador, New Brunswick and Nova Scotia. These strategies are a great example of multiple ministries working together, often with other sectors, in an integrated and focused way on a common goal that can result in significant health and other benefits to individuals and society at large. In addition, poverty-reduction strategies help inform governments about the determinants of health and the value of a whole-of-government approach.
In Ontario, many structural and organizational changes have taken place to focus attention on the determinants of health and to facilitate an intersectoral approach to the issues. The establishment of a Ministry of Health Promotion and Sport and the Ontario Agency for Health Protection and Promotion are key examples of this focus.
In addition, the government is exploring a Health in All Policies approach to population health, which involves embedding a health equity impact assessment tool into the development of all policies throughout government.
Ontario’s focus on poverty reduction includes projects stretching across ministries and involving external non-governmental organizations. Ontario’s Poverty Reduction Strategy was launched in December 2008 with a target of reducing the number of children living in poverty by 25% within five years. The strategy involves multi-ministry initiatives such as Ontario’s After-School Program, which brings citizens, the business community and the non-profit sector together. This program includes initiatives in education, community development, and social assistance.
The Healthy Communities Fund is a new approach from the Ministry of Health Promotion and Sport which supports community partnerships to plan integrated programs to improve the population’s overall health. It achieves this through awarding grants, partnerships and resources to programs that address several risk factors, facilitate intersectoral arrangements, and address knowledge transfer arising from successful outputs of the project. The goal of this fund is to create a culture of health, build healthy communities, create policies and programs that make it easier for Ontarians to be healthy, and enhance community leaders’ ability to work together on healthy living issues.
Quebec has demonstrated a long-standing commitment to public health and the reduction of health inequities. The province is a leader in the use of health impact assessment, a structured method to evaluate the potential impact of policies or programs on the population’s health.
In 2001, a new Public Health Act empowered the Minister of Health and Social Services to undertake intersectoral action that supports public policy favourable to health. The legislation requires that all legislative and regulatory proposals from all departments be subject to mandatory health impact assessment. For example, this approach has been used to regulate asbestos mining and ban cellphone use in cars.
Other provinces and territories
There are many other established and promising initiatives across the country. Some selected examples:
British Columbia’s ActNow BC is a major multi-sector health promotion effort that seeks to address common risk factors and reduce chronic disease. The initiative is carried out through partnerships at the community and provincial levels, and between public and private sectors. ActNow BC has been used as a model for further horizontal policy work across the province in mental health, addictions and chronic disease. All provincial ministries are required to support the health promotion and chronic disease prevention goals of the province, and the work is supported by a cross-government committee.
Alberta and Saskatchewan are developing forms of health impact assessment to address health inequities. In Alberta, the government recently released a major health report that will rewrite provincial legislation recognizing the determinants of health. Saskatchewan has initiatives such as the Human Service Integration Forum, a senior government body that leads provincial intersectoral policy work among the human service sectors.
Manitoba has established one of the most advanced whole-of-government initiatives in Canada, Healthy Child Manitoba. The strategy was implemented in 2000, and the Healthy Child Manitoba Act proclaimed in 2007. The mandate is a long-term, cross-governmental initiative across economic and social justice spheres. Healthy Child Manitoba works across departments to facilitate community development approaches that support the well-being of children, families and communities.
Newfoundland and Labrador, Nova Scotia, and Prince Edward Island are using Community Accounts, a free online database that provides community and regional statistics on issues such as health, income, education and employment. These systems are particularly important for allowing access to good data to build a business case and set targets for the determinants of health.
In the Northwest Territories, A Foundation for Change: Building a Healthy Future for the NWT 2009-2012, provides a framework for intersectoral projects in areas such as family violence, homelessness, persons with disabilities, tobacco reduction, early childhood development, and injury prevention.
IV The need to step it up
The thought of tackling the determinants of health is often daunting to governments. The case for support is complex, and as a result is a tough sell. It is often difficult to convince elected politicians of the need to invest across many fronts to address health because the issues are intertwined and the investments needed are long-term. That type of approach represents a considerable shift in organizational culture. It takes time for decision-makers to understand that improving the health of Canadians is a job for the entire government, not just the ministries of health, which until now has been the prevailing view.
Despite these challenges, we know from research that there are certain conditions essential for success. At the heart of every successful government effort to address the determinants of health lies strong political and bureaucratic leadership. Committed individuals working as champions of the cause can create momentum for the whole-of-government process and support the structures necessary for success. It is critical that governments ensure they are clear about the issues they are targeting, and the goals and objectives to be achieved. A strong and compelling case for support accompanied by clear, bold numerical goals and targets helps build a stronger call to action. Lastly, having appropriate government structures to support action is essential. This could be a dedicated authority within government that coordinates activity across departments and sectors, or a steering committee of ministers and officials that is seen having the responsibility to act.
Involvement of community leaders and advocates has been identified as particularly important for the success of any whole-of-government approach. This must be accompanied by a concerted effort to involve and educate the public about the determinants of health to increase public and political support for government efforts.
Despite the extent of work across the country, our analysis confirms that research about health promotion and the determinants of health is not being translated into public policy and programs to the degree that we would like. Governments can no longer afford to organize their efforts in silos when it comes to the health of our populations; leaving the responsibility to one department or ministry is passé. The determinants of health are complex social issues that require the efforts of multiple agencies across multiple levels of government with the tacit involvement of the community and private sectors. With new urgency afforded to the determinants of health, we at the Health Council of Canada see a clear appetite for real action. The time has come to implement what will truly change the health of our country.
For more information about the determinants of health or to download the Health Council of Canada’s report, Stepping It Up: Moving the Focus from Health Care in Canada to a Healthier Canada, visit http://www.healthcouncilcanada.ca.